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Frailty care

​​​​​​​​​​The frailty care pathway is a specialised short-term service designed to manage frailty in elderly patients transitioning from Hospital in the Home service. This program focuses on patients who do not meet the criteria for existing home-based follow-up services, aiming to enhance their independence and reduce hospital readmissions.​​​

 Understanding frailty

​Frailty is characterised by reduced strength and endurance, increasing vulnerability to health stresses. This syndrome is often linked with higher risks of falls, longer hospital stays, and increased mortality.

 Our service approach

​Using the validated NSLHD frail scale, we classify patients as robust, pre-frail, or frail. This classification informs the customised care plans that address each patient's specific needs.

 Patient benefits

  • ​Virtual care coordination: The service includes a two-week virtual frailty program where patients participate in telehealth physiotherapy sessions focused on frailty management, education, and exercise.
  • Integrated care plans: We address complex needs including polypharmacy and nutritional requirements, with additional support from social work, dietetics, and clinical psychology.
  • Community integration: A crucial component of our pathway is linking patients with long-term community-based resources and services, ensuring continued support beyond our direct intervention.
  • Proactive monitoring and support: Our approach includes ongoing monitoring to quickly identify and respond to any medical issues or deteriorations, aiming to prevent emergency visits and ensure patient safety at home.

Contact us to access this service​

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We are here to help you navigate your health journey with the support of cutting-edge virtual care solutions.
​For more information on accessing this service contact us on:

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